Generalized anxiety disorder (GAD) is an anxiety disorder that
is characterized by excessive, uncontrollable and often irrational worry about
everyday things that is disproportionate to the actual source of worry. This
excessive worry often interferes with daily functioning, as individuals
suffering GAD typically catastrophise, anticipate disaster, and are overly
concerned about everyday matters such as health issues, money, death, family problems, friend problems or work
difficulties. They often
exhibit a variety of physical symptoms, including fatigue, fidgeting, headaches, nausea, numbness in hands and feet, muscle tension, muscle aches, difficulty swallowing, bouts of difficulty breathing, trembling, twitching, irritability, sweating, insomnia, hot flashes, and rashes. These symptoms must be consistent and on-going,
persisting at least 6 months, for a formal diagnosis of GAD to be introduced.
Approximately
6.8 million American
adults experience GAD.
Diagnosis
According to the Diagnostic and Statistical Manual IV-Text Revision
(DSM-IV-TR), the
following criteria must be met for a person to be diagnosed with Generalized
Anxiety Disorder.
- Excessive anxiety and worry (apprehensive expectation), occurring more days
than not for at least six months, about a number of events or activities (such
as work or school performance).
- The person finds it difficult to control the worry.
- The anxiety and worry are associated with three (or more) of the following
six symptoms (with at least some symptoms present for more days than not for the
past 6 months). Note: Only one item is required in children.
- restlessness or feeling keyed up or on edge
- being easily fatigued
- irritability
- muscle tension
- difficulty falling or staying asleep, or restless unsatisfying sleep
- difficulty concentrating or the mind going blank
Symptoms can also include nausea, vomiting, and chronic stomach aches.
- The focus of the anxiety and worry is not confined to features of an Axis I
disorder, e.g., the anxiety or worry is not about having a panic attack (as in panic disorder), being
embarrassed in public (as in social phobia), being away from home or close
relatives (as in Separation Anxiety Disorder),
gaining weight (as in anorexia nervosa), having multiple physical
complaints (as in somatization disorder), or having a
serious illness (as in hypochondriasis), and the anxiety and worry do
not occur exclusively during post-traumatic stress disorder.
- The anxiety, worry, or physical symptoms cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning.
- The disturbance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical condition
(e.g., hyperthyroidism) and does not occur exclusively
during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental
Disorder.
Epidemiology
The usual age of onset is variable - from childhood to late adulthood. Women
are two to three times more likely to suffer from generalized anxiety disorder
than men[6].
Potential Causes of GAD
Some research suggests that GAD may run in families,
and it may also grow worse during stress. GAD usually begins at an earlier age
and symptoms may manifest themselves more slowly than in most other anxiety
disorders. Some people with
GAD report onset in early adulthood, usually in response to a life stressor. Once GAD develops, it can be
chronic, but
can be managed, if not all-but-alleviated, with proper treatment.
Substance induced
In one study in 1988–1990
illness in
approximately half of patients attending mental health services at one hospital,
for conditions including anxiety disorders such as panic disorder or social
phobia, was determined to be the result of alcohol or benzodiazepine dependence. In these
patients, cessation of their anxiety symptoms corresponded with stopping the use
of the benzodiazepine or alcohol. Sometimes anxiety pre-existed alcohol or benzodiazepine dependence but the dependence
was acting to keep the anxiety disorders going and often progressively making
them worse. Recovery from benzodiazepines tends to take a lot longer than
recovery from alcohol but people can regain their previous good health. Symptoms
may temporarily worsen however, during alcohol
withdrawal or benzodiazepine withdrawal.
Self-help
Common-sense action may be taken to reduce the general level of anxiety. The
actions may be appropriate to a specific type of stress. For example, if there
are frequent worries about financial difficulties, then financial
planning may help. Other actions may improve general mental resilience. For
example, exercise
may help in releasing tension and, by improving fitness, enable the individual
to manage tasks more easily and feel better about himself or herself.
Treatment
A meta-analysis of 35 studies[12] shows the psychological method of cognitive behavioral therapy to be
more effective in the long term than pharmacologic treatment (drugs such as SSRIs), and while both
treatments reduce anxiety, CBT is more effective in reducing depression.
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT)
is a psychological method of treatment for GAD, which
involves a therapist working with the patient to understand how
thoughts and feelings influence behavior. The goal of
the therapy is to change negative thought patterns that lead to the patient's
anxiety, replacing them with positive, more realistic ones. Elements of the
therapy include exposure strategies to allow the patient to
gradually confront their anxieties and feel more comfortable in
anxiety-provoking situations, as well as to practise the skills they have
learned. CBT can be used alone or in conjunction with medication.
CBT usually helps one third of the patients substantially, whilst another
third does not respond at all to treatment.
SSRIs
Pharmaceutical treatments for GAD include selective serotonin reuptake
inhibitors (SSRIs), which are
antidepressants that influence brain chemistry to block the reabsorption of serotonin in the brain.
SSRIs are mainly
indicated for clinical depression, but are also very
effective in treating anxiety disorders. Common side
effects include nausea, sexual
dysfunction, headache, diarrhea, constipation, among
others. Common SSRIs prescribed for GAD include:
Other Drugs
Imipramine (Tofranil) is a tricyclic antidepressant (TCA). TCAs
are thought to act on serotonin, norepinephrine, and dopamine in the brain. Venlafaxine (Effexor) is a serotonin-norepinephrine
reuptake inhibitor (SNRI). SNRIs, a class of drugs related to the SSRIs,
alter the chemistries of both norepinephrine and serotonin in the brain.
Buspirone (BuSpar) is a serotonin
receptor agonist belonging to the azaspirodecanedione class of compounds.
Pregabalin (Lyrica) acts on the voltage-dependent calcium
channel in order to decrease the release of neurotransmitters such as
glutamate, noradrenaline and substance P.
Benzodiazepines
Benzodiazepines (or "benzos") are fast-acting
sedatives that
are also used to treat GAD and other anxiety
disorders.
These are
sometimes given in the short-term. Some are habit-forming and tolerance may develop.
Side effects include drowsiness, reduced motor coordination and problems with equilibrioception.
Common benzodiazepines used to treat GAD include
GAD and Comorbid Depression
In the National Comorbidity Survey (2005), 58% of patients diagnosed with major depression were found to have an
anxiety disorder; among these patients, the rate of comorbidity with GAD was
17.2%, and with panic
disorder, 9.9%. Patients with a diagnosed anxiety disorder also had high
rates of comorbid depression, including 22.4% of patients with social
phobia, 9.4% with agoraphobia, and 2.3% with panic disorder. For
many, the symptoms of both depression and anxiety are not severe enough (i.e.
are subsyndromal) to justify a primary diagnosis of either major depressive
disorder (MDD) or an anxiety disorder.
Patients can also be categorized as having mixed anxiety-depressive
disorder, and they are at significantly increased risk of developing
full-blown depression or anxiety. Appropriate treatment is necessary to
alleviate symptoms and prevent the emergence of more serious disease.
Accumulating evidence indicates that patients with comorbid depression and
anxiety tend to have greater illness severity and a lower treatment response
than those with either disorder alone.[citation needed] In
addition, social function and quality of life are more greatly impaired.
In addition to coexisting with depression, research shows that GAD often
coexists with substance
abuse or other conditions associated with stress, such as irritable
bowel syndrome. Patients
with physical symptoms such as insomnia or headaches should also tell their doctors about their
feelings of worry and tension. This will help the patient's health care provider
to recognize whether the person is suffering from GAD.
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